Medical Aid Insurance Forms

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INSURED

Region:

Name:

Address:

Cell No:

Tel No:

Fax No:

Email:

ID No:

VAT No:

LOSS/DAMAGE OCCURANCE

Date and Time of loss/damage:

When was loss/damage discovered?:

LOSS/DAMAGE PLACE

Place where loss/damage occurred:

(a)Were premises occupied?:

(b)By Whom?:

If not occupied when last occupied?:

Purpose of occupation: e.g. Office Space

CAUSE OF LOSS/DAMAGE

Describe fully how the loss or damage occurred stating how (if applicable) entry was gained to the premises:

If loss/damage caused by another party give name and address:

PREVIOUS LOSS/DAMAGE

Have you previously suffered a loss/damage?:

If so, give details:

If insured, provide name of insurer:

POLICE

Police Station:

Reference Number:

Date Reported:

OTHER INTEREST

Has any other party an interest in the insured property, e.g. Credit agreement:

If so, give name and interest:

OTHER INSURANCE

Is there any other insurance covering this loss?:

If so, give name of insurers:

VALUE

Estimated total of all the property, insured under the policy:

When last valued?:

PAYMENT METHOD

Name of bank:

Account Holder:

Branch Code:

Type of account:

Account number:

DECLARATION

I/We solemnly declare that I/we have suffered loss of or damage to the property enumerated and that the said property was in/my possession immediately prior to the said loss/damage which occurred in the circumstances described above.

Signature:

QTY	Description of Property	Date Acquired	Purchase Price	Amount Claimed
				Add

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